Provider First Line Business Practice Location Address:
4522 44TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92115-3140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-997-2454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/24/2017